53J Gandhara Med Dent Sci
October - December 2025
ORIGINAL ARTICLE
:
:
OUTCOME OF OPEN REDUCTION AND INTERNAL FIXATION BY USING ONE TITANIUM
PLATE AND ARCHBAR FOR THE MANAGEMENT OF MANDIBULAR FRACTURES IN
SYMPHYSEAL AND PARASYMPHYSEAL REGION
Abdul Wali Khan1, Khadija Syed2, Salman Khan3, Azmat Ali Safwan4, Abdus Saboor5,
Ajmal Khan6, Majida Rahim7
ABSTRACT
OBJECTIVES
To determine nerve injury, malocclusion, and non -union of ORIF using a
single miniplate and arch bar in the treatment of mandibular fractures in the
parasymphyseal and symphyseal regions.
METHODOLOGY
This descriptive cross-sectional study included 233 patients aged 13-65 years
who presented within 48 hours of sustaining non-comminuted symphyseal or
parasymphyseal mandibular fractures. Patients with bone pathologies,
systemic diseases affecting healing, infected fractures, contraindications to
general anesthesia, or who were unwilling to attend follow-up were excluded.
ORIF was performed using a single titanium miniplate and Erich arch bar
under general anesthesia. Outcomes were assessed at 4-week follow-up and
included inferior alveolar nerve (IAN) injury, malocclusion, and non-union.
Chi-square tests were used to evaluate associations between complications
and clinical variables.
RESULTS
The mean age of the participants was 32.42 ± 5.75 years, with 66.95% of
participants being male. Road traffic accidents were the leading cause
(56.65%). IAN injury was the most frequent complication (30.04%).
Malocclusion and non-union occurred in 2.58% and 1.72% of patients,
respectively. No statistically significant associations were found between
complications and age, gender, fracture type, or etiology.
CONCLUSION
Inferior alveolar nerve injury is the most common complication in
mandibular symphyseal and parasymphyseal fractures managed with ORIF,
warranting vigilant surgical technique and monitoring.
KEYWORDS: Mandible, Symphysis, Parasymphysis, Post-Operative
Complications
How to cite this article
Khan AW, Syed K, Khan S, Safwan
AA, Saboor A, Khan A, etal. Outcome
of Open Reduction and Internal
Fixation by Using One Titanium Plate
and Archbar for the Management of
Mandibular Fractures in Symphyseal
and Parasymphyseal Region. J Gandhara
Med Dent Sci.2025;12(4):53-57.https://
doi.org/10.37762/jgmds.12-4.753
Date of Submission: 07-07-2025
Date Revised: 21-09-2025
Date Acceptance: 22-09-2025
1Assistant Professor, Oral and
Dentistry, Swat
2Demonstrator, Oral and Maxillofacial
Swat
3Demonstrator Community Dentistry,
Saidu College of Dentistry, Swat
4Senior Demonstrator Oral Medicine,
Saidu College of Dentistry, Swat
6Professor, Oral and Maxillofacial
Surgery, Saidu College of Dentistry,
7Assistant, Professor, Oral Medicine,
Saidu College of Dentistry, Swat
Correspondence
5Abdus Saboor, Associate Professor and
HOD Oral Pathology, Saidu College of
Dentistry, Swat
+92-333-9464836
saboorppp@gmail.com
Maxillofacial Surgery, Saidu College of
Surgery, Saidu College of Dentistry,
Swat
INTRODUCTION
The mandible is the only mobile bone of the facial
skeleton that is involved in mastication, articulation,
and deglutition. It is also highly susceptible to
maxillofacial trauma due to its exposed anatomical
position.1 The site of a mandibular fracture is
influenced mainly by the mechanism of injury,
magnitude, and vector of impact, and anatomical
factors such as osseous morphology and muscle
attachment sites.2 Common etiologies of mandibular
fractures include motor vehicle collisions, interpersonal
violence, accidental falls, ballistic trauma, sports-
related trauma, and occupational injuries.3 Motor
vehicle collisions occur more frequently in regions with
inadequate traffic regulation, while other regions may
show a higher incidence of injuries related to
interpersonal aggression or athletic activities.4
Maxillofacial surgeons find it a challenging procedure
to treat a mandibular fracture; it requires specialized
expertise and well-equipped hospital facilities.5 The
choice of treatment is influenced by various factors like
chronological age of the patient, the anatomical site and
classification of fracture, available clinical resources,
and the surgical proficiency of the operator.6 The
overall goals of management include the re-
establishment of pre-traumatic occlusion, restoration of
craniofacial aesthetics and physiological function, and
aiming to attain them with minimal post-operative
complications and in an economically efficient
manner.7 Modern therapeutic strategies for mandibular
fractures include conservative management through
closed reduction with maxillomandibular fixation
(MMF) and operative intervention via open reduction
54 J Gandhara Med Dent Sci
October - December 2025
and internal fixation (ORIF), with or without MMF. 8
The advancement of surgical techniques has led to the
replacement of traditional methods, such as wire
osteosynthesis and prolonged MMF with ORIF, which
has demonstrated superior outcomes. Achieving rigid
stabilization of the fractured mandibular segments is
essential to permit regular functional activity and
support uneventful physiological healing.9 Significant
torsional forces are generated in the symphyseal and
parasymphyseal regions during mastication,
necessitating firm osteosynthesis of the fractured
segments.10 It is recommended that the application of
dual miniplate fixation: one along the inferior
mandibular border and another just apical to the dental
roots, functioning as a tension band to resist torsional
forces and enhance osseous healing at the fracture site.
Early functional mobilization is particularly critical in
pediatric populations to prevent temporomandibular
joint ankylosis.11 It also plays a vital role in averting
potentially fatal complications in patients with
neurological pathologies, combat-related injuries, or
polytrauma. Additionally, prompt mobilization helps
reduce the incidence of post-operative sequelae in
polytraumatized and immobilized individuals.12 The
purpose of this study is to determine nerve injury,
malocclusion, and non-union of ORIF using a single
miniplate and an arch bar as a tension band in the
management of mandibular fractures in the
parasymphyseal and body regions. This approach aims
to reduce the amount of implanted material without
compromising the stability at the fracture site. The
rationale behind this study is that using ORIF with one
titanium plate and an arch bar as a tension band for
managing mandibular fractures in the
symphyseal/parasymphyseal region can lessen the
implant burden at the fracture site, ultimately
decreasing morbidity and cost, minimizing post-
operative complications, and promoting earlier post-
operative functional recovery for patients.
METHODOLOGY
This descriptive cross-sectional study was conducted at
the Department of Oral and Maxillofacial Surgery,
Bacha Khan Medical College, Mardan, from January 1,
2024, to June 30, 2025, using non-probability
consecutive sampling. The sample size was 233,
calculated using the WHO software for sample size
determination with the following parameters: frequency
of inferior alveolar nerve injury following ORIF = 2%,
absolute precision required = 1.5%13, and confidence
interval = 95%. Patients aged 13-65 with symphyseal or
parasymphyseal mandibular fractures, occurring within
48 hours of injury, were included in this study, which
was approved by the institutional ethics committee
approved. Exclusion criteria included bone diseases,
contraindications to general anesthesia, infected
fractures, chronic systemic illnesses, and refusal to
participate in follow-up. A total of 233 patients were
selected from the outpatient department after obtaining
informed consent. Demographic data were collected,
and occupations were categorized into four
groups. Under general anesthesia, a surgical team
performed the treatment using arch bars secured with
0.75-gauge stainless steel wire for stabilization. After a
vestibular incision and subperiosteal dissection, the
fracture was exposed, with careful attention to the
mental nerve if near the fracture site. Two horizontally
placed 2.0 mm titanium miniplates with 7 mm screws
were used for fixation, followed by wound closure with
3/0 Vicryl sutures. A mandibular fracture was defined
as a break in the lower jawbone, with symphyseal and
parasymphyseal fractures specified. Outcomes were
measured clinically; the vertical overlap of incisors
defined malocclusion, while inferior alveolar nerve
(IAN) injury was assessed by lip numbness and two-
point discrimination testing. Non-union was indicated
by persistent bone displacement on radiographs. All
patients received antibiotics and analgesics, with
maxillomandibular fixation maintained for 10 days. A
researcher assessed patients 4 weeks post-surgery, and
the data were analyzed using SPSS version 20.0.
Numerical variables were described as mean ± SD, and
categorical variables were presented as frequencies and
percentages. A chi-square test was applied for stratified
outcomes (p ≤ 0.05 significance).
RESULTS
The study involved 233 participants (mean age, 32.4
years; SD, 5.8), predominantly male (66.95%), with
over half (51.15%) aged 30 years or younger. The
leading cause of mandibular fractures was road traffic
accidents (56.65%), followed by assault (27.47%) and
falls (15.88%). Parasymphysis fractures (54.51%) were
more common than symphysis fractures (45.49%).
Inferior alveolar nerve injury occurred in 30.04% of
patients, while malocclusion and non-union were rare,
affecting 2.58% and 1.72%, respectively. No significant
differences in complication rates were noted based on
gender or age. Inferior alveolar nerve injury was
highest among those injured in road traffic accidents
(34.1%), with no significant differences in
malocclusion or non-union rates across different causes.
Malocclusion rates were low in both fracture types
(2.8% for symphyseal and 2.4% for parasymphyseal),
with non-union slightly more common in symphyseal
fractures (2.8%) but not significantly.
Outcome of Open Reduction and Internal Fixation by Using
55J Gandhara Med Dent Sci
October - December 2025
Table 1: Demographic and Clinical Characteristics of the Study
Population
Variable n=233
Age (years), Mean(SD) 32.42 (5.75)
Gender Male 156 (66.95%)
Female 77 (33.05%)
Age group – Up to 30 years 120 (51.15%)
– More than 30 years 113 (48.49%)
Etiology of
Fracture
– Road traffic accident 132 (56.65%)
– Assault 64 (27.47%)
– Fall 37 (15.88%)
Type of
Mandibular
Fracture
-Symphysis 106(45.49%)
-Parasymphysis 127(54.51%)
Table 2: Frequency of Inferior Alveolar Nerve Injury,
Malocclusion, and Non-Union among Patients with Mandibular
Fractures in the Symphyseal and Parasymphyseal Region
Variable Yes No
Inferior Alveolar Nerve Injury 70 (30.04%) 163 (69.96%)
Malocclusion 06 (2.58%) 227 (97.42%)
Non-Union 04 (1.72%) 229 (98.28%)
Table 3: Frequency of inferior alveolar nerve injury,
malocclusion, and non-union among patients with mandibular
fractures by gender (n = 233)
Outcome Gender Yes (n/%) No (n/%) p-
value
Inferior
Alveolar
Nerve Injury
Male 46 (29.5%) 110 (70.5%) 0.79
Female 24 (31.2%) 53 (68.8%)
Malocclusion Male 04 (2.6%) 152 (97.4%) 0.99
Female 02 (2.6%) 75 (97.4%)
Non-Union Male 03 (1.9%) 153 (98.1%) 0.73
Female 01 (1.3%) 76 (98.7%)
Table 4: Malocclusion and Non-Union among Patients with
Mandibular Fractures in the Symphyseal and Parasymphyseal
Region by Age Group
Variable Age Group Yes No p
value
Inferior
Alveolar
Nerve
Injury
Up to 30
years
39 (32.5%) 81 (67.5%) 0.39
Above 30
years
31 (27.4%) 82 (72.6%)
Malocclusi
on
Up to 30
years
03 (2.5%) 117(97.5%) 0.93
Above 30
years
03 (2.7%) 110(97.3%)
Non-Union Up to 30
years
03 (2.5%) 117(97.5%) 0.34
Above 30
years
01 (0.9%) 112(99.1%)
Fisher’s exact test
Table 5: Frequency of Inferior Alveolar Nerve Injury,
Malocclusion, and Non-Union among Patients with Mandibular
Fractures by Etiology (N = 233)
Outcome Etiology Yes No p-
value
Inferior
Alveolar
Nerve
Injury
Road Traffic
Accident
45 (34.1) 87 (65.9) 0.19
Assault 18 (28.1) 46 (71.9)
Fall 07 (18.9) 30 (81.1)
Malocclus
ion
Road Traffic
Accident
04 (3.0) 128 (97.0) 0.83
Assault 01 (1.6) 63 (98.4)
Fall 01 (2.7) 36 (97.3)
Non-
Union
Road Traffic
Accident
02 (1.5) 130 (98.5) 0.88
Assault 01 (1.6) 63 (98.4)
Fall 01 (2.7) 36 (97.3)
*Fisher’s exact test
Table 6: Frequency of Inferior Alveolar Nerve Injury,
Malocclusion, and Non-Union among Patients with Mandibular
Fractures by Type of Fractures (N = 233)
Outcome Type of
Fracture
Yes (n/%) No (n/%) p-
value
Inferior
Alveolar
Nerve
Injury
Symphyseal 32 (30.2) 74 (69.8) 0.95
Parasymphys
eal
38 (29.9) 89 (70.1)
Malocclus
ion
Symphyseal 03 (2.8) 103 (97.2) 0.81
Parasymphys
eal
03 (2.4) 124 (97.6)
Non-
Union
Symphyseal 03 (2.8) 103 (97.2) 0.23
Parasymphys
eal
01 (0.8) 126 (99.2)
*Fisher’s exact test
DISCUSSION
In this study, the complication rate was 34.34%, with
inferior alveolar injury at 30.04% being the most
common. A review of 734 patients with 1,312
mandibular fractures found that assaults were the
leading cause, particularly affecting the
parasymphyseal, subcondylar, and angle regions. ORIF
was performed in 85% of cases, with fewer
intraoperative arch bars used for MMF and more
manual reductions. Among 228 patients with one or
two nonsubcondylar fractures, the complication rates
were similar: 12.9% for arch bars and 12.5% for
manual reduction, showing no significant difference in
surgical methods.14 A study from Larkana found that
80% of symphyseal and parasymphyseal fractures of
Outcome of Open Reduction and Internal Fixation by Using
56 J Gandhara Med Dent Sci
October - December 2025
the mandible were caused by road traffic accidents,
with 10% each due to physical assault and falls. This
aligns with our findings, though their most common
complication was infection (1%), while ours was nerve
injury.15 Another study on the effectiveness of ORIF for
mandibular fractures highlighted that motorcycle
accidents accounted for 88.4% of cases, involving 69
patients with a male-to-female ratio of 16.5:1 (94.2%
male). Patients ranged in age from 13 to 60 years, with
a mean age of 25.96 years, predominantly in the 21–30
age group. Left-sided fractures were more common,
and all patients had satisfactory healing with minimal
morbidity and no need for further surgery. No
significant morbidity or mortality was reported.16 The
investigation found a 30.04% rate of inferior alveolar
nerve (IAN) injury after mandibular fractures, with no
significant correlation to gender, age, or cause. In
contrast, Tariq et al. (2023) reported a 58.3%
perioperative IAN injury rate among 96 patients,
primarily male, with an average age of 35.8 years,
noting that 40.6% developed permanent neurosensory
deficits post-surgery. These differences underscore the
importance of fracture patterns and surgical techniques
in nerve preservation and monitoring.17 A case series
reported postoperative inferior alveolar nerve (IAN)
injuries in approximately 60% of cases, with persistent
neurosensory dysfunction in roughly 40% of patients.
This cohort had a mean age of 35.8 years and a male
predominance (78%).18 The 30% IAN injury rate in our
study aligns with previous reports, varying due to
factors like IAN anatomy and surgical technique.
Similar research on non-comminuted
symphysis/parasymphysis fractures treated with a
single miniplate noted a male predominance aged 20-45
years, with road traffic accidents as a primary cause. 19
This study reported minimal complications (3%
malocclusion, 4% wound infection), indicating
favorable outcomes. While both studies noted a male
predominance and motorcycle accidents as common
causes, complication types varied.
LIMITATIONS
A 4-week follow-up is insufficient to assess nerve
recovery after mandibular fractures. We cannot
effectively evaluate the risks of nerve injury because we
did not include a comparison group, like patients
treated with two-plate fixation. Additionally, we based
our assessment of nerve injury on what patients
reported and a two-point discrimination test, rather than
using more objective measures or a more extended
follow-up period.
CONCLUSIONS
In mandibular symphyseal and parasymphyseal
fractures, treatment with a single miniplate combined
with an arch bar tension band provides stable fixation
with minimal implant burden. The most common
complication was inferior alveolar nerve (IAN) injury,
occurring in 30% of cases, while malocclusion and non-
union were rare (<3%). The low incidence of infection
and other complications supports the safety and
effectiveness of the one-plate plus arch bar approach.
Clinicians should remain vigilant for IAN injury and
counsel patients accordingly, as early recognition and
management are important for optimal outcomes.
CONFLICT OF INTEREST: None
FUNDING SOURCES: None
REFERENCES
1. Ramirez CA, Fattahi T, Portnoff JE, Shaikh R, Margolis J,
Kraus JA, et al. Maxillofacial Trauma. In: Reti R, Findlay D,
editors. Oral Board Review for Oral and Maxillofacial Surgery.
Cham: Springer International Publishing; 2021. p. 179-200.
https://doi.org/10.1007/978-3-030-48880-2_7.
2. Inchingolo F, Patano A, Inchingolo AM, Riccaldo L, Morolla R,
Netti A, et al. Analysis of mandibular muscle variations
following condylar fractures: a systematic review. J Clin Med.
2023;12(18):5925. https://doi.org/10.3390/jcm12185925.
PMID: 37762866.
3. Maniaci A, Lentini M, Vaira L, Lavalle S, Ronsivalle S,
Rubulotta FM, et al. The global burden of maxillofacial trauma
in critical care: A narrative review of epidemiology, prevention,
economics, and outcomes. Medicina. 2025;61(5):915.
https://doi.org/10.3390/medicina61050915.
4. Dasukil S, Verma S, Jena AK, Mohapatra M. Frequency of
concomitant injuries in maxillofacial trauma in a tertiary health
care centre in India: a 5-year retrospective study. Chinese J
Traumatol. 2024;28(3):216-219.
https://doi.org/10.1016/j.cjtee.2024.03.008.
5. Kademani D. Dental, Oral, and Maxillofacial Emergencies. In:
Oral Medicine and Medically Complex Patients. 2025. p. 187-
243. https://doi.org/10.1002/9781119984382.ch5.
6. Diab J, Moore MH. Facial fractures in the elderly:
epidemiology, clinical characteristics, and management. Eur J
Plast Surg. 2021;44:577-86. https://doi.org/10.1007/s00238-
021-1800-w.
7. Polizzi A, Ronsivalle V, Lo Giudice A, Isola G, Bianchi A,
Santonocito S, et al. Orthodontic approaches in the management
of mandibular fractures: a scoping review. Children.
2023;10(3):605. https://doi.org/10.3390/children10030605.
8. Roccia F, Sobrero F, Raveggi E, Rabufetti A, Scolozzi P,
Dubron K, et al. European multicenter prospective analysis of
the use of maxillomandibular fixation for mandibular fractures
treated with open reduction and internal fixation. J Stomatol
Oral Maxillofac Surg. 2023;124(1):101376.
https://doi.org/10.1016/j.jormas.2022.101376.
9. Gadkaree SK, Derakhshan A, Nyabenda V, Ncogoza I,
Tuyishimire G, Shaye DA. Wire osteosynthesis in the treatment
of mandible fractures in low resource settings: a force study.
Craniomaxillofac Trauma Reconstr. 2024;17(1):13-7.
https://doi.org/10.1177/19433875221143605. PMID: 38371214.
10. Hamed S, Sweedan OA, Abou Eleneen HM. Screw retained
band wiring versus miniplates for treatment of anterior
mandibular fractures (randomized clinical trial). Alexandria
Dent J. 2025;10:1-7.
https://doi.org/10.21608/adjalexu.2025.344959.1582.
Outcome of Open Reduction and Internal Fixation by Using
57J Gandhara Med Dent Sci
October - December 2025
AUTHORS CONTRIBUTION
The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity of any part are properly investigated and resolved.
11. Vitkos EN, Papadopoulos KA, Dimasis P, Weissinger C,
Kyrgidis A. One miniplate versus two miniplates in the fixation
of mandibular angle fractures: an updated systematic review and
meta-analysis. J Stomatol Oral Maxillofac Surg.
2022;123(6):e865-e873.
https://doi.org/10.1016/j.jormas.2022.07.008.
12. Mahmoud NR, Habaka YF. Clinical efficacy of three plating
systems in management of mandibular parasymphyseal
fractures: a retrospective study. BMC Oral Health.
2024;24(1):1374. https://doi.org/10.186/s12903-024-05143-3.
13. Saman M, Kadakia S, Ducic Y. Post-operative
maxillomandibular fixation after open reduction of mandible
fractures. JAMA Facial Plast Surg. 2014;16(6):410-3.
https://doi.org/10.1001/jamafacial.2014.543. PMID: 25504647.
14. Kopp RW, Crozier DL, Goyal P, Kellman RM, Suryadevara
AC. Decade review of mandible fractures and arch bar impact
on outcomes of non-subcondylar fractures. Laryngoscope.
2016;126(3):596-601. https://doi.org/10.1002/lary.25671.
PMID: 26446363.
15. Shaikh Q. Clinical outcomes in mandibular fracture at
symphysis and parasymphysis region with miniplates under
local anesthesia in systemically compromised patients. Ann Pak
Inst Med Sci. 2014;10(3):140-4.
16. Hussain S, Mohammad S, Khan R. Effectiveness of ORIF by
using one titanium plate and arch bar for management of
mandibular fractures in parasymphyseal region. Pak J Med
Health Sci. 2010;4:61-4.
17. Tariq A, Kanwal S, Javed A, Jadoon Z, Khan SA, Ahmed M.
Frequency of inferior alveolar nerve damage after open
reduction and internal fixation in mandibular fractures:
frequency of inferior alveolar nerve damage. Pak J Health Sci.
2023:02-6. https://doi.org/10.54393/pjhs.v4i07.916.
18. Alamgir A, Ullah A, Tariq A, Mahmud A, Jadoon M, Siraj F.
Occurrence of inferior alveolar nerve damage after internal
fixation and open reduction in patients visiting Ayub Medical
College with mandibular fractures. Int J Health Sci. 7(S1):2739-
45. https://doi.org/10.53730/ijhs.v7nS1.14561.
19. Lone PA, Singh P, Kishore K, Goel M. Management of
mandibular symphysis and parasymphysis fractures using a
single mini plate with Erich arch bar: Our experience. JK Sci.
2017;19(2):119-23.
Abdul Wali Khan - Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Supervision;
Final Approval
Khadija Syed - Concept & Design; Data
Analysis/Interpretation; Drafting Manuscript; Final Approval
Salman Khan - Concept & Design; Data
Analysis/Interpretation; Drafting Manuscript; Final Approval
Azmat Ali Safwan - Concept & Design; Data
Analysis/Interpretation; Drafting Manuscript; Final Approval
Abdus Saboor - Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Supervision;
Final Approval
Ajmal Khan - Concept & Design; Data Analysis/Interpretation;
Drafting Manuscript; Supervision; Final Approval
Majida Rahim - Concept & Design; Data
Analysis/Interpretation; Drafting Manuscript; Final Approval
LICENSE: JGMDS publishes its articles under a Creative Commons Attribution Non-Commercial Share-Alike license (CC-BY-NC-SA 4.0).
COPYRIGHTS: Authors retain the rights without any restrictions to freely download, print, share and disseminate the article for any lawful purpose.
It includes scholarlynetworks such as Research Gate, Google Scholar, LinkedIn, Academia.edu, Twitter, and other academic or professional networking sites.
Outcome of Open Reduction and Internal Fixation by Using